Report to Congressional Requesters

United States General Accounting Office 

GAO 

January 2004 HUMANE METHODS 

OF SLAUGHTER ACT 

USDA Has Addressed 

Some Problems but 

Still Faces 

Enforcement 

Challenges 

GAO-04-247 
www.gao.gov/cgi-bin/getrpt?GAO-04-247.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Lawrence J. 

Dyckman at (202) 512-3841 or 

dyckmanl@gao.gov. 

Highlights of GAO-04-247, a report to 

Congressional Requesters 

January 2004 

HUMANE METHODS OF SLAUGHTER ACT 

USDA Has Addressed Some Problems 

but Still Faces Enforcement Challenges 

Incomplete and inconsistent inspection records made it difficult to 

determine the frequency and scope of humane handling and slaughter 

violations. FSIS was unable to produce at least 44 of its inspection records 

that document violations of the Humane Methods of Slaughter Act (HMSA) 

and implementing regulations. Also, inspectors did not always document 

violations of the HMSA because they may not have been aware of regulatory 

requirements. Further, the records that FSIS provided did not consistently 

document the scope and severity of each incident. USDA is taking steps to 

address these issues. 

Enforcement actions to address noncompliance with the act and regulations 

were also inconsistent. For example, we found that FSIS inspectors 

temporarily halted stunning operations in more than half of the cases 

involving ineffective stunning of a single animal, but in less than half of 

similar cases involving multiple animals. We also found that FSIS officials 

may not be using consistent criteria to suspend plant operations—the 

enforcement action used when serious or repeated violations of the HMSA 

occur. As a result, plants in different FSIS districts may not be subject to 

comparable enforcement actions. In November 2003, FSIS issued clearer 

guidance to its inspectors and field personnel that should help resolve some 

of these problems. 

FSIS lacks detailed information on how much time its inspectors spend on 

humane handling and slaughter activities making it difficult to determine if 

the number of inspectors is adequate. In general, FSIS officials believe that, 

with the introduction of a District Veterinary Medical Specialist at each of 

the agency’s field offices, the current number of personnel devoted to 

humane handling and slaughter compliance is adequate. 

Livestock Being Moved inside Slaughter Facility 

In 1978, the Congress passed the 

Humane Methods of Slaughter Act 

to ensure that cattle, sheep, hogs, 

and other animals destined for 

human consumption are handled 

and slaughtered humanely. Within 

the U.S. Department of Agriculture 

(USDA), the Food Safety and 

Inspection Service (FSIS) is 

responsible for enforcing the act. 

Recently, the Congress took 

additional actions to improve FSIS 

enforcement. GAO reviewed (1) the 

frequency and scope of humane 

handling and slaughter violations, 

(2) actions to enforce compliance, 

and (3) the adequacy of existing 

resources to enforce the act. 

GAO recommends that FSIS (1) 

record specific information on the 

type and causes of violations; (2) 

establish additional clear, specific, 

and consistent criteria for districts 

to use when considering 

enforcement because of repetitive 

violations; (3) require that districts 

and inspectors clearly document 

the basis for enforcement that are 

due to repetitive violations; (4) 

develop a mechanism for 

determining the level of effort 

inspectors devote to the HMSA; (5) 

develop criteria for determining the 

appropriate level of inspection 

resources needed; and (6) assess 

whether that level is sufficient to 

effectively enforce the act. FSIS 

generally agreed with our findings 

and recommendations. 
Page i GAO-04-247 Humane Methods of Slaughter 

Letter 1

Results in Brief 4

Background 6

The Most Prevalent Violation Was Ineffective Stunning, but the 

Overall Frequency and Scope of Humane Slaughter Violations Is 

Difficult to Determine 17

FSIS Took Inconsistent Enforcement Actions to Address 

Noncompliance 23

FSIS Data on Inspection Resources Devoted to Overseeing 

Humane Handling and Slaughter Requirements Are Inadequate 26

Conclusions 29

Recommendations for Executive Action 29

Agency Comments and Our Responses 30

Appendix I Scope and Methodology 31 

Appendix II Comments from the Food Safety and Inspection 

Service 34 

GAO Comments 38

Appendix III GAO Contacts and Staff Acknowledgments 40 

GAO Contacts 40

Acknowledgments 40

Table 

Table 1: Number of States and Slaughter Plants Covered by Each 

FSIS District, as of October 2002 11

Figures 

Figure 1: Stunning of Animals 8

Figure 2: Location of Plants Covered by the HMSA, as of October 

2002 9

Figure 3: Location of Plants Covered by the HMSA That Accounted 

for 80 Percent of U.S. Meat Production during Fiscal Year 

2002 10

Contents 
Page ii GAO-04-247 Humane Methods of Slaughter 

Figure 4: Location of Inspectors Observing Compliance with the 

HMSA at a Typical Mid-Size Plant 13

Figure 5: Violations Documented in Noncompliance Records 

between January 2001 and March 2003 21

Abbreviations 

DVMS District Veterinary Medical Specialist 

FSIS Food Safety and Inspection Service 

HMSA Humane Methods of Slaughter Act 

USDA U.S. Department of Agriculture 

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Page 1 GAO-04-247 Humane Methods of Slaughter 

January 30, 2004 

The Honorable Robert F. Bennett 

Chairman 

The Honorable Herb Kohl 

Ranking Minority Member 

Subcommittee on Agriculture, Rural Development, 

 and Related Agencies 

Committee on Appropriations 

United States Senate 

The Honorable Henry Bonilla 

Chairman 

The Honorable Marcy Kaptur 

Ranking Minority Member 

Subcommittee on Agriculture, Rural Development, 

 Food and Drug Administration, and Related Agencies 

Committee on Appropriations 

House of Representatives 

More than 125 million cattle, sheep, hogs, and other animals ultimately 

destined to provide meat for human consumption were slaughtered in 

fiscal year 2002, at some 900 federally inspected facilities throughout the 

United States. In response to public concerns about cruelty to livestock in 

meatpacking plants, the Congress passed the Humane Slaughter Act of 

1958. The act established as the policy of the United States that the 

slaughtering and handling of livestock be carried out only by humane 

methods. The act’s provisions applied only to plants desiring to sell meat 

to the federal government.1

 Twenty years later, the Congress passed the 

Humane Methods of Slaughter Act (HMSA) of 1978 to ensure that at all 

federally inspected slaughter establishments, not just those selling meat to 

the federal government, adopt humane handling and slaughter practices.2

In particular, the act specifies that animals must be quickly rendered 

insensible to pain before they are slaughtered. 

 1

Pub. L. No. 85-765, 72 Stat. 862 (1958). 

2

Pub. L. No. 95-445, 92 Stat. 1069 (1978). Among other things, the act amended sections 3 

and 10 of the Federal Meat Inspection Act, 21 U.S.C. sections 603 and 610. 

United States General Accounting Office

Washington, DC 20548 
Page 2 GAO-04-247 Humane Methods of Slaughter 

The Food Safety and Inspection Service (FSIS), within the U. S. 

Department of Agriculture (USDA), is responsible for enforcing the 

Humane Methods of Slaughter Act. FSIS inspection personnel are 

stationed at each federally inspected slaughter facility to examine every 

carcass to ensure that it is safe for human consumption. Although their 

responsibilities are primarily for food safety, these inspectors are also 

responsible for monitoring compliance with the act and the applicable 

regulations at slaughter facilities throughout the country. FSIS guidance 

states that when inspectors observe noncompliance with the act’s 

provisions, they should document the incident in a noncompliance record.3

Inspectors are also authorized to take enforcement action by temporarily 

shutting down parts of the plant’s operations until management provides 

satisfactory assurances that the situation will be promptly remedied. In 

more serious cases, the agency may temporarily suspend plant operations 

by removing FSIS inspectors from a part of the facility or from the entire 

facility until the problem is corrected. Finally, the FSIS administrator can 

file a complaint to withdraw the grants of inspection from a facility, which 

prevents its products from entering interstate or foreign commerce. By 

law, slaughter facilities cannot slaughter and process animals for sale in 

commerce without federal inspectors present.4

In recent years, the Congress has taken various actions to strengthen 

USDA’s resources and to better ensure that the agency enforces the 

humane handling and slaughter provisions of the act. In fiscal year 2001, 

the Congress earmarked funds for the agency to enhance humane 

slaughter practices.5

 In response, FSIS created the position of District 

Veterinary Medical Specialist (DVMS) in each of its districts. The DVMSs 

are the primary contacts for all humane handling and slaughter issues in 

each FSIS district office, and they are the liaisons between the district 

offices and headquarters on humane handling and slaughter issues. They 

are responsible for on-site coordination of nationally prescribed humane 

slaughter procedures and verification of humane handling activities, as 

well as dissemination of directives, notices, and other information related 

to the act. In fiscal year 2002, the Congress further directed that the 

Secretary of Agriculture should fully enforce the Humane Methods of 

 3

Throughout this report, we use the terms “noncompliance” and “violation” 

interchangeably. This is consistent with FSIS regulations and directives. 

4

7 U.S.C. sections 603, 604. 

5

Pub. L. No. 107-20, 115 Stat. 155, 164 (2001). 
Page 3 GAO-04-247 Humane Methods of Slaughter 

Slaughter Act and report annually to the Congress on the number of 

violations and trends recorded by FSIS inspectors.6

 Fiscal year 2003 

appropriations legislation included $5 million for additional inspection 

activities.7

 Also, in a recent congressional conference report for fiscal year 

2003 appropriations, the conferees directed us to review and report to the 

appropriations committees on the scope and frequency of humane 

slaughter violations and to provide recommendations on the extent to 

which additional resources for inspection personnel, training, and other 

agency functions are needed to properly regulate slaughter facilities.8

In response to this congressional directive, and through subsequent 

discussions with your staff, we (1) analyzed the frequency and scope of 

humane handling and slaughter noncompliance incidents documented by 

FSIS inspectors, (2) analyzed FSIS actions to enforce compliance with 

humane handling and slaughter provisions, and (3) assessed the extent to 

which additional resources may be needed to ensure that humane 

handling and slaughter provisions are enforced. To perform our work, we 

obtained and analyzed all available FSIS records of noncompliance with 

humane handling and slaughter requirements between January 2001 and 

March 2003. We reviewed enforcement actions that the FSIS inspectors 

took between January 2001 and March 2003 and that FSIS district 

managers took between October 2001 and July 2003. To obtain 

information on resources dedicated to humane handling and slaughter 

oversight, we interviewed FSIS program officials and reviewed available 

workforce data. We also reviewed all of the completed DVMS summary 

reports that outline the officials’ overall observations after each plant visit. 

To obtain their views on the adequacy of personnel and training resources, 

we conducted structured interviews with district managers, deputy district 

managers, and DVMSs in all 15 FSIS districts. Finally, we obtained the 

views of humane slaughter experts, industry association representatives, 

and animal welfare groups. We conducted our work between April 2003 

and November 2003 in accordance with generally accepted government 

auditing standards. Appendix I describes our methodology in more detail. 

 6

Farm Security and Rural Investment Act of 2002, Pub. L. 107-171, Section 10305 116 Stat. 

134. 

7

Pub. L. No. 108-7, 117 Stat. 11, 22 (2003). 

8

H. Conf. Rep. No. 108-10 (2003). 
Page 4 GAO-04-247 Humane Methods of Slaughter 

Incomplete and inconsistent FSIS inspection records made it difficult to 

determine the frequency and scope of humane handling and slaughter 

violations. Available FSIS records show that during the 28 months 

between January 2001 and March 2003, inspectors wrote 553 

noncompliance records to document violations of the HMSA and the 

implementing regulations at 272 facilities across the United States. 

According to these inspection records, ineffective stunning, which does 

not quickly render animals insensible to pain as required by the act, was 

the most prevalent type of noncompliance. To a lesser extent, the records 

documented poor facility conditions that could lead to animal injury and 

failure to provide water to animals awaiting slaughter as other prevalent 

violations. However, in conducting this analysis, we found internal control 

problems that call into question the reliability of FSIS’s records regarding 

compliance with the act. First, because the agency had not stored its 

noncompliance records in electronic form, it could not provide us with at 

least 44 additional records from the period between January 2001 and 

March 2003. In addition, almost half of the DVMSs with whom we spoke 

reported that inspectors did not always document noncompliance when 

they should have because they were unsure about regulatory 

requirements; for example, they were not sure if a violation was too minor 

to be documented. Second, the noncompliance records did not 

consistently document the scope and severity of violations. Inspectors are 

required to document HMSA noncompliance through narrative that 

includes the applicable statutory or regulatory provision, a concise 

description of the violation, and any other relevant evidence; but the 

records show that inspectors did not describe violations in a consistent 

manner. For example, while some noncompliance records provided 

detailed information on the causes of observed ineffective stunning and 

the number of animals impacted, other records only mentioned that 

ineffective stunning occurred but provided no additional details. 

Incomplete and inconsistent data can make it difficult for FSIS to 

accurately assess compliance with the act and to report the results to the 

Congress. Despite these data limitations, in its March 2003 report to the 

Congress, USDA indicated that during fiscal year 2002 “very few 

infractions were for actual inhumane treatment of the animals.” Officials 

informed us that their analysis was based on a sample of approximately 

half of the noncompliance records available. In contrast, our analysis of all 

of the noncompliance records FSIS provided for fiscal year 2002 shows 

that one fourth of the 366 noncompliance incidents documented by 

inspectors, were for incidents of ineffective stunning—a violation that 

USDA characterized in its report to the Congress as “actual inhumane 

treatment.” FSIS has made recent efforts to improve documentation, 

Results in Brief 
Page 5 GAO-04-247 Humane Methods of Slaughter 

including better tracking of documentation and new guidance to 

inspectors. 

FSIS took inconsistent enforcement actions to address noncompliance 

with the HMSA. For example, we found that plant inspectors temporarily 

halted stunning operations in more than half of the cases involving 

ineffective stunning of a single animal, but in less than half of similar cases 

involving multiple animals. Half of the DVMSs we interviewed attributed 

the inconsistent enforcement actions to inspectors’ inexperience, lack of 

clarity regarding their authority, or the misperception that certain 

violations are minor. We found similar inconsistencies at the district 

management level. District managers can decide to take the more serious 

enforcement action of withdrawing inspectors from the plant, thus 

suspending a plant’s operations, when they are notified of serious 

violations. However, they lack clear criteria on when to do so, and this can 

lead to inconsistencies in enforcement. We found, for example, one case in 

which a district manager did not suspend plant operations after inspectors 

had issued 16 noncompliance records to a slaughter facility documenting 

the plant’s failure to properly stun animals. In contrast, another facility’s 

failure to provide access to water and to maintain acceptable pen 

conditions led to a suspension of operations. As a result, FSIS cannot 

ensure that humane slaughter requirements are consistently enforced 

across districts, undermining FSIS efforts to effectively enforce the act. In 

November 2003, FSIS issued guidance that should help inspectors 

determine when it is appropriate for them to take enforcement actions. 

However, the guidance is less explicit about when district actions are 

warranted. For example, the guidance does not identify thresholds at 

which repetitive instances of noncompliance at the same facility would 

require action by district officials. 

FSIS does not have data on the number of inspectors devoted to 

compliance with the HMSA or on the amount of time that inspectors spend 

on humane handling and slaughter requirements. Without such 

information, FSIS cannot determine the appropriate number of inspectors 

for different sized plants or the number of inspectors needed overall to 

effectively enforce the act. FSIS headquarters and district officials believe 

that, for the most part, the current number of inspectors is sufficient to 

monitor and enforce humane handling and slaughter requirements. In 

particular, district officials believe that the present number of DVMSs is 

adequate to cover each district’s HMSA responsibilities. However, the 

officials said that despite improvements made by the hands-on training 

provided by DVMSs, they remain concerned about inspectors’ overall level 

of knowledge regarding HMSA requirements. When we discussed this 
Page 6 GAO-04-247 Humane Methods of Slaughter 

matter with FSIS headquarters officials, they said that, in addition to the 

new November 2003 directive that provides clearer guidance, the agency is 

currently taking steps to improve inspectors’ knowledge. For example, the 

agency is developing scenarios for inspectors that will illustrate how to 

implement the HMSA requirements. 

To help ensure adequate enforcement of the HMSA, we are recommending 

that the Secretary of Agriculture direct FSIS to (1) include in 

noncompliance records specific information on the type and cause of 

violations, (2) establish additional criteria for when districts are to take 

enforcement actions in cases of repetitive violations, (3) require that 

district offices and inspectors clearly document the basis for enforcement 

actions that they take in response to repetitive violations, (4) develop a 

mechanism for determining the level of resources that the agency devotes 

to humane handling and slaughter activities, (5) develop criteria for 

determining the appropriate level of inspection resources, and (6) 

periodically assess whether that level is sufficient to effectively enforce 

the act. 

FSIS commented on a draft of this report and generally agreed with our 

findings and recommendations. FSIS also provided a number of specific 

comments, which we incorporated in the report as appropriate. 

The Congress passed the Humane Slaughter Act in 1958 in response to 

intense and broad-based public concerns about cruelty and abuse of 

livestock in meat-packing plants.9

 At that time, the Congress determined 

that using humane methods of slaughter prevented the needless suffering 

of livestock, resulted in safer and better working conditions for 

employees, and brought about improvements in products and economies 

of slaughter operations, among other benefits. The act established as U. S. 

policy that the handling and slaughtering of livestock should be carried out 

using humane methods. However, the act applied only to plants wishing to 

sell meat products to federal government agencies. In 1978, the Congress 

passed the HMSA, which amended the Federal Meat Inspection Act and 

extended the policy nationwide by requiring that all federally inspected 

slaughter establishments adopt humane handling and slaughter methods. 

The HMSA requires that animals be “rendered insensible to pain by a 

single blow or gunshot or an electrical, chemical or other means that is 

 9

Pub. L. No. 85-765, 72 Stat. 862 (1958). 

Background 
Page 7 GAO-04-247 Humane Methods of Slaughter 

rapid and effective, before being shackled, hoisted, thrown, cast, or cut.”10

The act also provides for a ritual slaughter exemption that allows the 

slaughter of animals in accordance with the ritual requirements of any 

faith “that prescribes a method of slaughter whereby the animal suffers 

loss of consciousness by anemia of the brain caused by the simultaneous 

and instantaneous severance of the carotid arteries with a sharp 

instrument and handling in connection with such slaughtering.”11

FSIS has issued regulations and directives to enforce the act. Important 

requirements of these regulations and guidance include the following: 

• All animals must be effectively stunned before they are slaughtered. 

Stunning is effective when the animal feels no pain, is rendered instantly 

unconscious, and remains unconscious until slaughtered; 

• Dragging of disabled and other animals unable to move, while conscious, 

is prohibited; 

• All holding pens and driveways and ramps must be designed, built, and 

maintained to prevent injury to livestock; 

• Livestock should be provided with water in holding pens, and food if held 

for more than 24 hours; 

• The use of electrical prods and other devices to move livestock must not 

be excessive and should be used as little as possible. 

 107 U.S.C. Section 1902 (a). The act applies to those establishments processing cattle, 

calves, horses, mules, sheep, goats, pigs, and other equines. It does not apply to poultry, 

bison, reindeer, and catalo. 

117 U.S.C. Section 1902 (b). 
Page 8 GAO-04-247 Humane Methods of Slaughter 

Figure 1 illustrates two separate stunning efforts—-one of a cow being 

stunned with a mechanical captive bolt and another of a sheep being 

stunned with an electrical stunner. 

Figure 1: Stunning of Animals 
Page 9 GAO-04-247 Humane Methods of Slaughter 

As of October 2002, 918 plants were covered by the HMSA in the United 

States. Figure 2 shows the distribution of these plants. 

Figure 2: Location of Plants Covered by the HMSA, as of October 2002 

While the plants are concentrated heavily in the Northeast, they tend to be 

smaller plants. The 49 large producers, who account for approximately 80 

percent of total production of meat in the country during fiscal year 2002, 

are mainly located in the Midwest, as figure 3 illustrates. 
Page 10 GAO-04-247 Humane Methods of Slaughter 

Figure 3: Location of Plants Covered by the HMSA That Accounted for 80 Percent of U.S. Meat Production during Fiscal Year 

2002 

FSIS is responsible for ensuring compliance with the Humane Methods of 

Slaughter Act.12 The FSIS is organized into 15 district offices that include: 

Alameda, Albany, Atlanta, Beltsville, Boulder, Chicago, Dallas, Des 

Moines, Jackson, Lawrence, Madison, Minneapolis, Philadelphia, Raleigh, 

and Springdale. Table 1 shows the states, number of plants, and type of 

plant, by size, for each FSIS district.13

 12The FSIS is also responsible for ensuring the safety of most meat, poultry, and processed 

egg products. 

13FSIS classifies plants according to their size: large plants—those with 500 or more 

employees, small plants—those with 10 to 499 employees, and very small plants—those 

with fewer than 10 employees, or annual sales of less than $2.5 million. 
Page 11 GAO-04-247 Humane Methods of Slaughter 

Table 1: Number of States and Slaughter Plants Covered by Each FSIS District, as of October 2002 

 Plants covered by the HMSA 

FSIS District States Covered Very small plants Small plants Large plants Total plantsa

Alameda CA 4 25 3 32

Albany CT,ME,MA,NH,NY,RI,VT 71 4 0 75

Atlanta FL, GA, PR, VI 50 12 0 62

Beltsville DE, D.C., MD, VA, WV 26 13 2 41

Boulder AZ, CO, NM, NV, UT, AK, AS, 

GU, HI, ID, OR, WA 79 15 8 102

Chicago IL, IN, OH 25 28 6 59

Dallas TX 17 27 4 48

Des Moines IA, NE 23 18 18 59

Jackson AL, MS, TN 25 11 2 38

Lawrence KS, MO 52 8 9 69

Madison MI, WI 33 10 4 47

Minneapolis MN, MT, ND, SD, WY 26 32 7 65

Philadelphia PA, NJ 112 23 3 139

Raleigh NC, SC, KY 36 14 4 54

Springdale AR, LA, OK 20 7 1 28

Total 599 247 71 918

Source: GAO presentation of FSIS data. 

a

FSIS did not provide size information for one plant, so the total number of plants under the three size 

categories does not equal 918. 

In 2002, FSIS employed about 7,600 inspectors at red-meat plants and 

poultry facilities to inspect each carcass after it is slaughtered to ensure 

that it is safe for human consumption.14 Inspectors include at least one 

veterinarian assigned to each plant, who is required to evaluate the general 

health of animals before they are slaughtered, and Consumer Safety 

Inspectors, who are not veterinarians and have varying inspection 

responsibilities throughout the plant.15 FSIS officials maintain that as they 

carry out their food safety and other activities, all inspectors are 

responsible for monitoring compliance with humane handling and 

 14FSIS did not provide us with the specific number of inspectors that are assigned to meat 

slaughter facilities. 

15Throughout this report, we refer to veterinarians and Consumer Safety Inspectors as 

“inspectors.” 
Page 12 GAO-04-247 Humane Methods of Slaughter 

slaughter requirements at plants that are covered by the HMSA from the 

time livestock come into the custody of the plant to the time of slaughter. 

According to the FSIS, while the HMSA requires inspectors to observe the 

entire handling and slaughter process, inspectors do not have to observe 

all animals all the time for HMSA compliance. In contrast, the Federal 

Meat Inspection Act requires that each animal be examined prior to 

slaughter and each carcass be individually inspected after slaughter to 

ensure that the meat is safe for human consumption.16

Typically, animals arrive on plant premises, are unloaded from trucks, and 

then are held in the stockyard area where FSIS inspectors perform the 

required antemortem inspection. During this inspection, disabled animals 

are separated from the herd. Animals are then moved through curved 

holding chutes and forcing pens onto the stunning platform, where they 

are stunned before being slaughtered. Figure 4 illustrates the areas in a 

typical, mid-size plant from which inspectors can observe for HMSA 

compliance, although inspectors are not always present in all areas. 

 167 U.S.C. sections 603, 604. 
Page 13 GAO-04-247 Humane Methods of Slaughter 

Figure 4: Location of Inspectors Observing Compliance with the HMSA at a Typical Mid-Size Plant 

When inspectors observe a violation of the HMSA or its implementing 

regulations, they are required to notify plant management and document, 

with a noncompliance record, the violation and the actions taken by the 
Page 14 GAO-04-247 Humane Methods of Slaughter 

plant to correct it. Inspectors can document more than one violation, and 

different types of violations, in a single noncompliance record. According 

to FSIS guidance, each noncompliance record should include the 

following information:17

• A unique record number, 

• The date of the violation, 

• The plant identification number, 

• Humane handling regulations applicable to the incident reported, 

• A written description of the violation, 

• The name of plant personnel notified of the violation, and 

• The plant management’s written response stating both the immediate 

action to correct the violation and any subsequent action to prevent its 

recurrence. 

In response to HMSA noncompliance, FSIS can take a number of 

enforcement actions—actions that impose restrictions on a facility’s 

ability to operate. These actions include the following: 

• For less serious violations of the HMSA, inspectors at a facility can issue a 

“reject tag” to quickly respond to violations that management can readily 

address. Inspectors physically place these reject tags on a piece of 

equipment or an area of the plant. This action temporarily prohibits the 

use of a particular piece of equipment or area of the facility until the 

violation is corrected. 

• For more serious violations, the district manager can suspend inspection 

until the violation or violations are addressed.18 This action, which 

removes FSIS inspectors from facility premises (or part of the facility), 

suspends operations at the facility (or part of the facility) because 

slaughter facilities may not operate without federal inspectors present. 

 17FSIS Directive 5001.1, Revision 1: Verifying an Establishment’s Food Safety System, May 

21, 2003. 

18If there is an egregious situation of inhumane handling and slaughter, the inspector in 

charge may also immediately suspend inspection and immediately notify USDA’s district 

office for prompt documentation of the suspension action. 
Page 15 GAO-04-247 Humane Methods of Slaughter 

• In cases where a plant fails to respond to FSIS concerns about repeated 

and/or serious violations, the administrator of FSIS can withdraw 

inspection. This enforcement action removes the grant of inspection from 

a facility, which prevents the facility’s products from entering interstate 

and foreign commerce. The facility must reapply for and be awarded a 

grant of inspection before it may resume operations. This action is rarely 

used. 

Agency supplemental appropriations in 2001 included $3 million, of which 

no less than $1 million was to be used to enhance the agency’s humane 

slaughter practices.19 USDA used $1.25 million of these funds to hire 17 

DVMSs to serve as program coordinators for all humane handling issues. 

By March 2002, a DVMS was at work in each of the FSIS district offices. 

The DVMSs, who received extensive training on humane handling and 

slaughter techniques and related inspection procedures, are the primary 

contacts for inspectors in each FSIS district office and the liaisons 

between the district offices and headquarters on humane handling and 

slaughter compliance. As of May 2003, the 17 DVMSs had visited 576, or 

about 63 percent, of 918 plants covered by the HMSA. Thirteen of the 16 

DVMSs we interviewed said that they had visited all or almost all of their 

assigned plants at least once. According to these 16 DVMSs, when they 

came on board, all of them participated in a number of district activities 

that went beyond the scope of humane handling and slaughter of animals, 

such as biosecurity and food safety issues. For example, nine DVMSs 

reported that these activities took 40 to 50 percent of their time. In March 

2003, however, an FSIS memorandum directed all but five of the DVMSs to 

only perform humane handling activities.20 As a result, the activities of 12 

DVMSs changed, and their current focus is solely the implementation of 

the HMSA. 

Despite these actions, concerns about the treatment of animals at U.S. 

slaughterhouses persist. For example, two animal welfare groups, the 

Humane Society of the United States and the Humane Farming 

Association, believe that enforcement of the act could be improved. These 

groups maintain that more continuous monitoring of compliance with the 

 19Pub. L. No. 107-20 (2001). 

20FSIS determined the DVMSs who would only perform humane handling and slaughter 

related work after sending a survey to all DVMSs asking them if they would be interested in 

performing only HMSA work or if they would like to perform other duties. The other five 

DVMSs still have humane handling responsibilities, but can also assist with food safety and 

food security. 
Page 16 GAO-04-247 Humane Methods of Slaughter 

HMSA is necessary. Also, according to the Humane Society, USDA 

oversight is especially critical at facilities that specialize in disabled 

animals and old dairy cattle, as well as those with slaughter production 

lines that operate at high speeds. 

Conversely, meat industry associations we contacted maintain that the 

way animals are handled and slaughtered has improved in response to 

pressure from customers of fast food restaurants and industry audits of 

slaughter establishments. When Dr. Temple Grandin, a renowned animal 

science authority, conducted a survey of 24 slaughterhouses in 1996 at 

USDA’s request, she found that only 36 percent were able to stun 95 

percent of the cattle on the first try.21 When she repeated the survey in 

2002, this time visiting 80 different plants, she found that 94 percent were 

able to do so.22 While Dr. Grandin’s second survey shows a significant 

improvement, it still indicates that hundreds of thousands of animals were 

not stunned on the first try, as required by the act. Thus, there may be 

undetected instances of inhumane treatment. Dr. Grandin believes that 

effectively stunning animals on the first try 100 percent of the time is 

unachievable—that is why she proposed an objective scoring method as 

an alternative. Objective scoring uses definite thresholds for various types 

of humane handling and slaughter incidents and provides a means to 

promote consistency within and across slaughter establishments. When 

we discussed the objective scoring approach with FSIS officials, they 

pointed out that the approach may have merit, particularly as a monitoring 

tool. However, the officials pointed out that the HMSA requires that 

animals be effectively stunned on the first try with one single blow or 

gunshot. Therefore, objective scoring would not be an appropriate 

regulatory tool because it allows for less than 100 percent effectiveness in 

stunning. That is, under the objective scoring method, a plant’s humane 

slaughter procedures would be considered adequate if, for example, 95 

percent of the animals were stunned with one single blow or gunshot on 

the first try. 

 21Survey of Stunning and Handling in Federally Inspected Beef, Veal, Pork, and Sheep 

Slaughter Plants; Agricultural Research Service, USDA. 3602-20-00, January 7, 1997. 

222002 Restaurant Audits of Stunning and Handling in Federally Inspected Beef and Pork 

Slaughter Plants; http://www.grandin.com/survey/2002.restaurant.audits.html. 
Page 17 GAO-04-247 Humane Methods of Slaughter 

Our ability to assess the frequency and scope of noncompliance with the 

HMSA was limited because FSIS could not provide us with documentation 

for all of the noncompliance incidents and because the documentation 

provided was not always complete and consistent. The 553 noncompliance 

records that the agency provided to us show that, between January 2001 

and March 2003, there were 675 HMSA violations at 272 facilities—

approximately 30 percent of the more than 900 slaughter facilities in the 

United States. The most prevalent noncompliance documented was the 

ineffective stunning of animals, in many cases resulting in a conscious 

animal reaching slaughter. FSIS has made recent efforts to improve 

documentation—including steps to improve inspector awareness of 

documentation requirements, better tracking of noncompliance 

documents, and issuing new HMSA guidance in November 2003. 

The universe of inspection records that FSIS provided to us was 

incomplete, making it difficult to assess the frequency of noncompliance 

with the HMSA. FSIS provided us with 553 documented records of 

noncompliance with the act and the implementing regulations covering the 

28-month period from January 2001 through March 2003. However, we 

found internal control problems that call into question the reliability of the 

information in the FSIS records regarding HMSA compliance. Our analysis 

indicates that the extent of noncompliance with the HMSA and the 

implementing regulations is likely to be greater than what is reflected in 

the 553 records for several reasons. First, according to FSIS officials, 

inspectors wrote at least 44 additional noncompliance records during this 

period—January 2001 to March 2003. However, while their recordkeeping 

system indicates that these noncompliance records exist, the agency could 

not locate the actual noncompliance documents for our review. The 

officials said that the records were not electronically stored and that they 

would rather improve tracking of such documentation in the future than 

attempt to locate the missing records. This internal control problem is 

being addressed, according to FSIS officials, because the agency has 

transitioned to a system that stores all noncompliance records 

electronically. Second, according to several DVMSs’ observations during 

their in-plant evaluations of humane slaughter activities, the frequency of 

noncompliance with the act is likely to be underreported. At least 7 of the 

16 DVMSs we spoke with believe that inspectors have not always 

documented violations in noncompliance records when they should. The 

DVMSs said that some inspectors were not always aware of regulatory 

requirements and may have felt documentation was unnecessary because 

they either determined the offense was not serious or that it could be 

easily remedied. The principal guidance provided to inspectors—known as 

The Most Prevalent 

Violation Was 

Ineffective Stunning, 

but the Overall 

Frequency and Scope 

of Humane Slaughter 

Violations Is Difficult 

to Determine 

Inspection Records Were 

Incomplete and 

Inconsistent, Making It 

Difficult to Determine the 

Frequency and Scope of 

Noncompliance 
Page 18 GAO-04-247 Humane Methods of Slaughter 

the “Rules of Practice”—does not specifically instruct inspectors on 

whether to document a violation if that violation does not result in an 

enforcement action and leaves it to the discretion of the inspector when 

an enforcement action is called for.23 However, recently, FSIS issued a 

directive that requires inspectors to document all violations in 

noncompliance records. Third, because inspectors do not engage in 

continuous animal by animal observation for humane handling and 

slaughter compliance purposes, violations may occur that are not 

recorded by inspectors. 

Our ability to determine the overall scope and severity of humane 

slaughter violations was further limited by the inconsistent way inspectors 

document violations in noncompliance records. Inspectors describe 

noncompliances by narrative—for example, by specifying whether the 

violation involved ineffective stunning or lack of access to water. Our 

analysis of noncompliance records related to HMSA showed that 

inspectors do not describe violations in a consistent manner and their 

narratives can vary substantially. For example, while some noncompliance 

records provide detailed information on the observed causes of ineffective 

stunning and the exact number of animals impacted, other records only 

mention that ineffective stunning occurred. Additionally, because 

narrative is the only way an inspector can describe the HMSA 

noncompliance, the agency cannot easily extract and analyze information. 

Inspectors do include a code so that violations related to HMSA can be 

distinguished from violations related to food safety, but it is a universal 

code for all HMSA violations; and it does not provide any additional 

information about the type or severity of the violation.24 As a result, it is 

difficult for FSIS to quantify, interpret, and report the data related to the 

scope and severity of documented instances of noncompliance. 

 23FSIS issued its “Rules of Practice” in September 5, 2001, in FSIS Notice 36-01 to ensure 

that all inspection program personnel are knowledgeable about the enforcement actions 

that the agency may take, the circumstances under which the various types of enforcement 

actions are appropriate and can be taken, and the procedures that the agency will follow in 

doing so. According to FSIS, the rules of practice provide a key link between inspection 

and enforcement activities. The guidance elaborates on the regulatory enforcement actions 

described at 9 C.F.R. pt. 500. In November 2003, FSIS issued a new directive to its 

inspection personnel that provides clearer direction regarding enforcement. 

24This contrasts with the dozens of ways that inspectors can classify different types of food 

safety violations ranging from sanitation procedures to labeling accuracy. 
Page 19 GAO-04-247 Humane Methods of Slaughter 

Incomplete and inconsistent data can make it difficult for FSIS to 

adequately assess how well HMSA standards are being enforced and to 

report those results to the Congress and other interested parties. In 2002 

legislation, the Congress stated that USDA should track violations of the 

HMSA and report the results and relevant trends annually to the Congress. 

In its March 2003 report to the Congress,25 USDA reported that during 

fiscal year 2002 it documented 379 noncompliance incidents out of 70,403 

times when inspectors made observations for compliance with the HMSA. 

This averages to approximately six observations for HMSA compliance per 

month, or less than two observations per week, for each the 918 plants 

that are covered by the act. By analyzing approximately half of the 

noncompliance records available for fiscal year 2002, FSIS concluded in 

the report that the majority of these violations were related to facility 

conditions (e.g., slippery flooring, large gap between pen bars, etc.) and 

animals provisions (failure to provide water or food). It then concluded 

that “very few infractions were for actual inhumane treatment of the 

animals (e.g. dragging or ineffective stunning).” 

However, our evaluation of USDA’s data showed otherwise. We analyzed 

all the available noncompliance records for fiscal year 2002 and identified 

366 noncompliance incidents, of which 92 (one-fourth) were for 

ineffective stunning—a violation that USDA characterizes as “actual 

inhumane treatment.” Likely reasons for the discrepancy between our 

analysis and USDA’s report are that we analyzed all available records, 

while FSIS officials told us that USDA’s analysis was based on a 

subjectively selected sample of approximately half of the available 

records. Additionally, FSIS’s violation documentation system—specifically 

its sole reliance on narrative to document HMSA violations—required both 

FSIS officials and us to interpret the inspectors’ narratives to identify the 

number and types of violations identified in the documentation. The FSIS 

official who conducted the analysis told us that upon close examination of 

these narratives, some instances that appear to be cases of direct animal 

injury in fact were not and would therefore not be considered by the 

agency to be actual inhumane treatment of animals.26

 25See Food Safety and Inspection Service, Humane Handling and Slaughter Enforcement 

Activities, Report to Congress, March 2003. 

26USDA only provided us with four examples of cases where they did not consider the 

reported violation to have caused direct injury to animals, therefore resulting in actual 

inhumane treatment of animals. 
Page 20 GAO-04-247 Humane Methods of Slaughter 

We found similar results when we analyzed noncompliance records over a 

longer period—January 2001 to March 2003. During this period, FSIS 

produced 553 noncompliance records indicating some type of 

noncompliance with the HMSA. These noncompliance records were 

written for 272 plants, or about 30 percent, of the 918 plants that were 

covered by the act. Our analysis of these noncompliance records identified 

675 violations. Of these violations, 167 were for ineffective stunning, 

meaning animals were not quickly rendered insensible to pain as required 

by the HMSA and the implementing regulations. We found that over 67 

percent of the 167 ineffective stunning violations resulted in conscious 

animals being slaughtered. Other less prevalent violations included facility 

conditions that could lead to animal injury and lack of access to water. 

Our interviews with the DVMSs support these data. Among the 16 DVMSs 

we spoke with, the most prevalent violations they reported observing 

when they visited plants to evaluate humane handling and slaughter 

practices were ineffective stunning, poor facility conditions, and lack of 

access to water. Figure 5 summarizes the types of violations we identified, 

using FSIS documentation. 
Page 21 GAO-04-247 Humane Methods of Slaughter 

Figure 5: Violations Documented in Noncompliance Records between January 2001 

and March 2003 

Note: Our analysis of the 553 noncompliance records identified 675 violations. A noncompliance 

record can include more than one violation. 

a

The ineffective stunning and conscious animals columns in the figure are not mutually exclusive. 

Specifically, in 112 cases, ineffective stunning resulted in one or more conscious animals moving to 

slaughter. In 55 cases, ineffective stunning was documented but not that a conscious animal was 

slaughtered. This could happen if, for example, multiple stunning efforts were required to render the 

animal unconscious. In 21 cases, inspectors noted that an animal was observed to be conscious at 

slaughter, without indicating ineffective stunning. This could happen if an animal regained 

consciousness after being effectively stunned. 

FSIS has recently taken steps to improve inspector awareness of 

documentation requirements and to correct the limitations in its 

inspection documentation process. According to DVMSs and other FSIS 

district officials with whom we spoke, as the DVMSs began playing an 

active role in working with inspectors at plants covered by the HMSA, the 

inspectors’ level of knowledge regarding interpreting and documenting 

noncompliance has improved. In particular, DVMSs told us that inspectors 

are becoming more aware of the need to document noncompliance 

incidents that previously may have been considered to be too minor to 

document or may not have been considered a violation at all. As a result, 

the number of documented records for noncompliance incidents increased 

FSIS Is Taking Steps to 

Improve Inspector 

Awareness of 

Documentation 

Requirements and 

Introduced Changes in Its 

Documentation Process 
Page 22 GAO-04-247 Humane Methods of Slaughter 

from January 2001 through March 2003. For example, in the first quarter of 

fiscal year 2002, FSIS inspectors issued 56 noncompliance records 

documenting HMSA violations. This number increased to 134 in the first 

quarter of fiscal year 2003. Similarly, the number of noncompliance 

incidents documenting relatively minor violations increased as well. For 

example, during the same time frames, documented incidents for facility 

conditions that could cause injury to animals prior to slaughter increased 

from 5 to 40, and documented incidents of lack of access to water 

increased from 9 to 37. The DVMSs attributed the increase in part to the 

enhanced awareness of humane handling and noncompliance 

documentation requirements on the part of the inspectors. 

Additionally, FSIS officials told us that the introduction of a humane 

handling procedure code in its Performance Based Inspection System (the 

computer-based system it uses to track compliance with all FSIS 

regulations), which took effect in October 2001, should help FSIS better 

track noncompliance records that document HMSA violations. While this 

change may address the agency’s internal control problems regarding 

record maintenance, it will not, as we discussed earlier, provide sufficient 

data on the type of HMSA violations or make it easier for the agency to 

quantify, interpret, and report the data related to the scope and severity of 

the documented noncompliances. 

FSIS also released a new directive, “Humane Handling and Slaughter of 

Livestock,” in November 2003.27 This directive also provides additional 

guidance and informs inspectors on many aspects of HMSA compliance. 

Importantly, the directive specifically instructs inspectors to document all 

violations of the HMSA and implementing regulations, regardless of the 

severity of the violation or whether an enforcement action is called for. 

 27FSIS Directive 6900.2, “Humane Handling and Slaughter of Livestock,” November 25, 

2003. This directive informs inspectors of the requirements, verification activities, and 

enforcement actions for ensuring that the handling and slaughter of livestock, including the 

slaughter of livestock by religious ritual methods, is humane. The directive also explains 

how inspectors should approach these activities. Specifically, the directive leads the reader 

through the existing regulatory requirements and explains in simple, easy to read and 

understand language how inspection program personnel should verify compliance with 

each of these regulations and what actions they should take if there is noncompliance. 
Page 23 GAO-04-247 Humane Methods of Slaughter 

Our review of noncompliance records indicates that FSIS has taken 

inconsistent enforcement actions in response to violations of the Humane 

Methods of Slaughter Act and applicable regulations. Inspectors stationed 

in slaughter plants have not consistently issued “reject tags”—the 

enforcement action used for less serious violations—to temporarily stop a 

plant from using a piece of equipment or an area of the plant until the 

violation is corrected or appropriate actions are taken to prevent 

recurrence of the incident. Also, district managers were not using 

consistent criteria to suspend plant operations when more serious 

violations occurred. 

FSIS inspectors took enforcement actions in almost 40 percent of the 

documented noncompliance cases between January 2001 and March 2003. 

FSIS officials and guidance indicate that it is not appropriate to take an 

enforcement action for all violations. For example, while stunning an 

animal more than once is clearly an instance of noncompliance with 

humane handling and slaughter requirements, an inspector may not feel 

that an enforcement action is necessary if a plant employee stuns an 

animal more than once because of certain unavoidable conditions, such as 

an animal moving its head just prior to being stunned. 

Nevertheless, our analysis of the noncompliance records indicates that 

inspectors are not consistently taking enforcement actions. Specifically, 

they are not consistently using reject tags.28 The records show that serious 

violations appear to have taken place—violations that involved multiple 

instances of ineffective stunning or several animals being conscious during 

slaughter—but that inspectors did not take any enforcement action. For 

example, our analysis of enforcement actions taken in the 167 instances of 

ineffective stunning shows that inspectors used reject tags to temporarily 

suspend stunning operations in more than half of the 86 cases involving 

ineffective stunning of a single animal but in less than half of the 79 cases 

that involved multiple animals.29 In one particular incident, the inspector 

who prepared the noncompliance record wrote that he observed six 

 28From January 2001 through March 2003, inspectors issued reject tags to temporarily 

interrupt the use of equipment or facilities or to slow down or stop production lines 214 

times. The most prevalent reasons for these reject tags were ineffective stunning and 

conscious animals observed being slaughtered. 

29While our analysis included 167 instances of ineffective stunning, we could not determine 

from the documentation provided how many animals were impacted in two of these cases. 

Therefore, this analysis is based on 165 incidents. 

FSIS Took 

Inconsistent 

Enforcement Actions 

to Address 

Noncompliance 

Records Show Inspectors 

Took Inconsistent 

Enforcement Actions in 

Response to 

Noncompliance 
Page 24 GAO-04-247 Humane Methods of Slaughter 

conscious animals being slaughtered during a period of 5 minutes, and he 

considered the incident unacceptable; however, he did not take 

enforcement action. This inaction was in sharp contrast to many other 

cases where inspectors took enforcement actions, for relatively less 

serious violations, such as lack of access to water. 

According to half of the 16 DVMSs we interviewed, inspectors often do not 

take enforcement action when they should. DVMSs attribute this 

inconsistent use of enforcement action to several factors. For example, 

some inspectors are hesitant to issue reject tags for ineffectively stunned 

animals because they are not veterinarians and are unsure about what 

signs indicate that an animal is still conscious after it has been stunned. 

They also noted that some inspectors lack the experience or knowledge 

regarding their authority to issue reject tags or simply misinterpret routine 

incidents—even though they are violations—as not warranting 

enforcement actions. FSIS did not provide data for the level of experience 

of inspectors. However, as part of the inspectors’ new hire program, FSIS 

includes a module on humane handling issues; inspectors have no other 

formal training on the HMSA and its enforcement. Most of the deputy 

district managers and half of the DVMSs noted that an overall lack of 

knowledge among inspectors about how they should respond to an 

observed noncompliance has been a problem in enforcing the HMSA. 

FSIS has begun to address the problem of unclear guidance by issuing a 

new humane handling and slaughter directive on November 25, 2003. This 

directive, for the first time, clearly states that inspectors are obligated to 

take enforcement actions when they observe inhumane treatment whether 

or not animal injury has resulted. Specifically, the directive states that 

inspectors must take action if either (1) a violation of humane handling 

and slaughter requirements has occurred that is not immediately causing 

injury or inhumane treatment of animals and the establishment has not 

taken appropriate preventative actions or (2) a violation of HMSA 

requirements has occurred and animals are being injured or treated 

inhumanely. Also, FSIS officials said that they have recently held meetings 

with the DVMSs and district officials that focused on making enforcement 

more consistent. 

In addition to the enforcement actions available to inspectors stationed at 

slaughter facilities, district managers may suspend the operations of an 

entire facility, or part of the facility, by removing the inspectors from the 

plant. Since FSIS inspectors must be present during slaughter operations, 

this effectively shuts down a facility. This enforcement action is more 

District Managers Have 

Also Taken Inconsistent 

Enforcement Actions 
Page 25 GAO-04-247 Humane Methods of Slaughter 

serious than the reject tags that inspectors can use and may be taken by 

district managers in the event of serious or repetitive violations. Between 

October 2001 and July 2003, district managers issued eight suspensions at 

seven slaughter plants that directly involved HMSA violations. According 

to FSIS, seven of the suspensions were issued in response to incidents 

involving the physical treatment of animals—four in response to 

inappropriate stunning or conscious animals observed at slaughter, two in 

response to the mistreatment of disabled animals, and one in response to 

excessive use of electric prods and force. One suspension was issued in 

response to facility conditions (a protruding fence board that was pointing 

toward the animals and could cause injury) and lack of access to water. In 

addition, during the same period, FSIS districts issued four letters to 

plants to inform them that if corrective actions were not taken to prevent 

recurrence of noncompliance incidents, the districts would proceed with 

suspension action. 

Our analysis of the 553 noncompliance records indicated that the severity 

and repetitiveness of the violations does not necessarily result in 

consistent enforcement actions by district managers. For example, in one 

case, inspectors had prepared 16 noncompliance records, all related to the 

ineffective stunning of animals. However, the district manager did not take 

enforcement action because, as he explained, the 16 incidents were not 

triggered by the same factor; if they had been, he said he would have 

suspended the plant. This contrasts with the opinion of another district 

manager who, commenting on this same situation, said that a case of so 

many related and relatively serious incidents is a definite candidate for a 

suspension. 

District managers said that they identify facilities for suspension by 

reviewing the noncompliance records and looking for “red-flags”—

specifically, cases of serious and/or repetitive incidents of inhumane 

treatment of animals. While FSIS guidance stipulates that district level 

enforcement actions, such as suspensions, are appropriate when facilities 

have been unable to implement corrective and preventive actions in 

response to previously identified violations, the guidance does not contain 

suggested thresholds or criteria on when district actions are appropriate. 

More specifically, the guidance does not address how many repetitive 

instances of noncompliance should warrant district level enforcement 

actions. In the absence of uniform criteria, these enforcement decisions 

are likely to be inconsistent across FSIS districts, undermining FSIS’ 

efforts to effectively enforce the act. 
Page 26 GAO-04-247 Humane Methods of Slaughter 

While the November 2003 directive provides some additional guidance on 

when suspensions are an appropriate response to multiple violations with 

the same or related cause, it does not provide any information on the 

number of related violations that would warrant a suspension. For 

example, in deciding whether a suspension is warranted, the directive 

states that district officials should consider the amount of time between 

violations—not the number of repeat violations—taken by the plant. FSIS 

officials noted that they have recently held meetings to emphasize 

consistent enforcement and discussed the issue at the October 2003 

National Supervisory Conference attended by over 200 agency field 

supervisors. 

Because FSIS does not have adequate data on the number of inspectors 

responsible for enforcing the HMSA or the actual time they spend on 

humane handling and slaughter requirements—nor other information, 

such as criteria to determine the appropriate number of inspectors for 

different sized plants—it is difficult to determine if the number of 

inspectors is adequate to effectively enforce the HMSA. However, FSIS 

headquarters and district officials believe that, for the most part, personnel 

resources dedicated to monitoring and enforcing humane handling and 

slaughter requirements are adequate. District officials believe that the 

present number of DVMSs is adequate to cover each district’s HMSA 

responsibilities. The DVMSs are the primary contacts for inspectors in 

each FSIS district office and the liaisons between the district offices and 

headquarters on humane handling and slaughter issues. They are 

responsible for on-site coordination of nationally prescribed humane 

slaughter procedures and verification of humane handling activities, as 

well as dissemination of directives, notices, and other information related 

to the act. Fifteen districts have one DVMS and two districts, Boulder and 

Chicago, have two DVMSs each.30 According to FSIS district officials, the 

17 DVMSs are sufficient to oversee humane handling and slaughter 

activities in each district. 

 30This was the result of an FSIS realignment of its district offices. When USDA introduced 

the DVMS position, it assigned one DVMS to each of its 17 districts. In May 2002, an 

organizational realignment consolidated FSIS’s 17 district offices into 15. In the 

realignment, the Pickerington, Ohio, office became a satellite office in the Chicago district, 

and the Salem, Oregon, office became a satellite office in the Boulder, Colorado, district. As 

a result, the Chicago and Boulder districts now have two DVMSs each. 

FSIS Data on 

Inspection Resources 

Devoted to 

Overseeing Humane 

Handling and 

Slaughter 

Requirements Are 

Inadequate 
Page 27 GAO-04-247 Humane Methods of Slaughter 

FSIS officials could not, however, provide us with quantitative data on the 

actual time in-plant inspectors spend enforcing HMSA or other 

quantitative data from which we could assess the adequacy of in-plant 

inspection resources dedicated to humane handling and slaughter. Without 

this basic information, it is difficult to determine with any degree of 

certainty or precision if the number of inspectors is adequate to effectively 

enforce the HMSA. Also, without this data, FSIS cannot determine the 

appropriate number of inspectors for different sized plants or the adequate 

number of inspectors overall to effectively enforce the act. FSIS recently 

conducted an analysis showing that inspectors spent an estimated 132,405 

hours, or 63 full-time equivalents, on humane handling and slaughter 

activities in fiscal year 2003. To come up with this estimate, the agency 

asked the DVMSs to estimate the number of hours that inspectors spent 

observing humane handling, per shift per plant in their districts. The 

DVMSs aggregated this information to determine how many total hours, 

per plant per year, were spent on humane handing and slaughter. 

Additionally, FSIS officials said they have a pilot program in place to track 

hours spent enforcing the HMSA. However, without additional 

information, such as criteria to determine the appropriate number of 

inspectors for different sized plants, the agency has insufficient 

information to make good decisions regarding how to allocate inspectors, 

and we could not conclusively determine whether additional in-plant 

inspectors are needed to ensure compliance with the HMSA. 

Nevertheless, discussions with district officials suggest that additional 

resources devoted solely to enforcing the HMSA are not needed, but that 

additional inspectors who could conduct both food safety and humane 

handling activities would be beneficial. District managers and their 

deputies were in general agreement that there is no need for additional 

inspectors whose sole responsibility would be to observe for compliance 

with the HMSA. Five of the 29 district officials we spoke with who 

disagreed with this position told us that dedicated HMSA inspectors would 

be beneficial, primarily at larger plants only, or to supplement and follow 

up on the DVMSs’ work when DVMSs are not present at a plant. However, 

almost 40 percent of the district managers and their deputies reported a 

general need for additional inspectors—inspectors responsible for both 

humane handling and food safety. They noted that filling current vacancies 

and/or hiring more relief inspectors to cover for vacations and other 

expected and unexpected leave would benefit HMSA enforcement. Several 

officials said this would be true particularly in larger plants where the size 

and configuration of the facility make it difficult for inspectors to 

effectively monitor humane handling and food safety compliance at the 

same time. 
Page 28 GAO-04-247 Humane Methods of Slaughter 

While stating that personnel resources for overseeing handling and 

slaughter requirements appear overall adequate, district officials 

expressed some dissatisfaction with the inspectors’ overall level of 

knowledge about humane handling and slaughter requirements. According 

to 17 of the 29 district officials and at least 9 of the 16 DVMSs we 

interviewed, despite improvements made by the hands-on training that 

DVMSs provided inspectors, additional training of inspectors would 

improve the agency’s ability to properly enforce the HMSA. Additionally, 

14 DVMSs said that not all inspectors are fully knowledgeable about the 

requirements of the HMSA or the implementing regulations—including not 

being aware that certain actions are violations of the HMSA, or what their 

authority and obligations are when a violation has been observed. FSIS 

officials also believe that inspector knowledge needs to be improved, and 

they said that they are committed to doing this through additional training 

and other efforts. We agree that this is a reasonable first step—improving 

existing personnel’s knowledge—before making decisions about the need 

for additional resources. Accordingly, we are not making a 

recommendation that FSIS provide additional training. 

When we discussed this matter with senior FSIS officials, they said that 

they are currently taking steps to improve inspectors’ knowledge. As a first 

step, with the assistance of the DVMSs, FSIS is developing a survey of 

veterinarians’ and other supervisory inspectors’ overall training needs, 

including needs in the area of humane handling and slaughter.31

Additionally, the agency’s November 2003 directive consolidates many 

HMSA requirements into a single directive, making it easier for inspectors 

to understand and interpret the requirements. DVMSs are also developing 

scenarios that will illustrate to inspectors how to implement the HMSA 

requirements and help them better understand their job function as it 

relates to the act. These scenarios are distributed in the form of a monthly 

report (Humane Interactive Knowledge Exchange—HIKE) that FSIS 

employees will be able to access through the Internet.32 FSIS officials 

believe that this will be a successful way of sharing knowledge throughout 

the agency on key policy issues. 

 31FSIS senior officials said that the reason they are sending this survey primarily to 

veterinarians at this point is because Consumer Safety Inspectors are unionized, which 

makes implementation of a survey instrument to them a cumbersome and lengthy process. 

32The first HIKE was issued in the fall of 2003. 
Page 29 GAO-04-247 Humane Methods of Slaughter 

The Congress first passed legislation in 1958 and subsequently in 1978 to 

address humane treatment of livestock. Recently, the Congress also 

provided USDA with additional resources and directed the Secretary of 

Agriculture to fully enforce the HMSA and implementing regulations. In 

response, FSIS created the DVMS position. According to many district 

officials, this step has enhanced knowledge among slaughter plant 

inspectors about their duties to ensure the humane handling and slaughter 

of animals. Additionally, very recent efforts, such as the new directive for 

inspectors, demonstrate a commitment to improving enforcement of the 

act. However, FSIS still faces challenges. The agency needs to address 

shortcomings related to adequately recording and analyzing documented 

instances of noncompliance with the HMSA and ensure consistent 

application of enforcement actions before it can assure the Congress and 

the pubic that animals are treated humanely and the act is being fully 

enforced. Finally, the lack of information on the level of effort FSIS 

dedicates to humane handling and slaughter activities prevents it from 

evaluating its own performance and making informed decisions on 

whether additional inspectors are needed. 

We are making six recommendations to the Secretary of Agriculture to 

further strengthen the agency’s oversight of humane handling and 

slaughter methods at federally inspected facilities. 

To provide more quantifiable and informative data on violations of the 

HMSA, we recommend that the Secretary of Agriculture direct FSIS to 

• supplement the narrative found in noncompliance records with more 

specific codes that classify the types and causes of humane handling and 

slaughter violations. 

To ensure that district officials use uniform and consistent criteria when 

taking enforcement actions, we recommend that the Secretary of 

Agriculture direct FSIS to 

• establish additional clear, specific, and consistent criteria for district 

offices to use when considering whether to take enforcement actions 

because of repetitive violations; 

• require that district offices and inspectors clearly document the basis for 

their decisions regarding enforcement actions that are based on repetitive 

violations. 

Conclusions 

Recommendations for 

Executive Action 
Page 30 GAO-04-247 Humane Methods of Slaughter 

To ensure that FSIS can make well-informed estimates about the 

resources it needs to enforce the Humane Methods of Slaughter Act, we 

recommend that the Secretary of Agriculture direct FSIS to 

• develop a mechanism for identifying the level of effort that inspectors 

currently devote to monitoring humane handling and slaughter activities; 

• develop criteria for determining the level of inspection resources that are 

appropriate on the basis of plant size, configuration, or history of 

compliance, once the mechanism is developed and in operation; and 

• periodically, assess whether that level is sufficient to effectively enforce 

the act. 

We provided FSIS with a draft of this report for their review and comment. 

FSIS generally agreed with our findings and recommendations. In addition, 

FSIS provided a number of specific comments and clarifications, which we 

incorporated as appropriate. FSIS’s comments and our responses to them 

appear in appendix II. 

We are sending copies of this report to the Secretary of Agriculture and 

interested congressional committees. We will also provide copies to others 

on request. In addition, the report will be available at no charge on the 

GAO Web site at http://www.gao.gov.

If you or your staff have any questions, please call me at (202) 512-3841. 

Contributors to this report are listed in appendix III. 

Lawrence J. Dyckman 

Director, Natural Resources 

 and Environment 

Agency Comments 

and Our Responses 
Appendix I: Scope and Methodology 

Page 31 GAO-04-247 Humane Methods of Slaughter 

To assess the scope and frequency of humane handling and slaughter 

violations, we obtained and analyzed data from several sources. First, we 

obtained the U.S. Department of Agriculture’s March 2003 Report to 

Congress on Humane Handling and Slaughter Enforcement Activities, in 

which USDA presents their findings on noncompliance with the Humane 

Methods of Slaughter Act (HMSA) during fiscal year 2002. We reviewed 

that information and followed up with the Food Safety and Inspection 

Service (FSIS) officials who wrote the report to discuss the methodology 

they used when they conducted their analysis. Second, in structured 

interviews with 16 of the 17 District Veterinary Medical Specialists 

(DVMS), we discussed what they thought were the most common types of 

noncompliance with the HMSA, based on their visits to plants covered by 

the act in their districts. In addition, we also reviewed the written 

summaries that they prepared to document these observations. Third, we 

obtained from FSIS all available documentation of observed violations to 

the HMSA for the period January 2001 through March 2003, the period for 

which FSIS could provide us with the most complete documentation. This 

information was provided in the form of 553 records of noncompliance. To 

analyze this information provided in these forms and determine the 

frequency of violations, by type of violation, as well as their scope, we 

classified them as follows: 

• Ineffective stunning (i.e., one or more animals had to be stunned more 

than once); 

• One or more conscious animals showed signs of consciousness past the 

stun box, i.e, when they were hoisted, cut, or bled; 

• Facility conditions that either caused injury to an animal or could cause 

injury to an animal, such as broken fences, protruding nails, slippery 

floors, and overcrowded pens; 

• Excessive use of electric prods or other devices; 

• Mishandling of ambulatory animals, such as hitting, kicking, or dragging a 

conscious animal; 

• Mishandling of disabled animals, such as keeping such animals among 

ambulatory animals, increasing the risk of further injury; 

• Lack of access to water; 

• Lack of access to food; and 

Appendix I: Scope and Methodology 
Appendix I: Scope and Methodology 

Page 32 GAO-04-247 Humane Methods of Slaughter 

• Other instances of noncompliance with the HMSA or applicable 

regulations. 

Using these categories, we aggregated the information to determine the 

frequency of the various types of violations. In addition, to obtain a further 

indication of the “scope” of the violation for cases where animals were 

ineffectively stunned or where conscious animals were observed past the 

stun box, we created a code indicating whether a single animal or multiple 

animals were impacted. A GAO analyst knowledgeable of the subject 

matter conducted all the classifications. A second GAO analyst reviewed 

all forms and codes determined by the first analyst for accuracy. Any 

discrepancies were resolved through discussion between the two analysts. 

We also discussed our methodology with FSIS officials who did not have 

any objections with our approach. 

To further evaluate the information presented in the 553 reports, we 

reviewed FSIS regulations and guidance to inspectors regarding when they 

are required to write a noncompliance record and what they are supposed 

to include in it. In addition, in our structured interviews with 16 of 17 

DVMSs, we obtained their views on inspectors’ documentation of 

noncompliance and factors, if any, which may impact it. 

To determine FSIS actions to enforce compliance with the humane 

handling and slaughter requirements, we obtained information on 

enforcement actions taken at the plant and FSIS district level. To 

determine how many times inspectors took enforcement actions, and 

under what circumstances, we analyzed the 553 noncompliance records 

we obtained from FSIS for the period between January 2001 and March 

2003. We analyzed the narrative information in these records to determine 

when inspectors temporarily stopped use of equipment or part of the plant 

in response to a violation and for what type of violation. To determine how 

many times district managers took enforcement actions, we obtained and 

analyzed documentation for all plant suspensions and notices of intended 

enforcement actions by a district, for the period between October 2001 

and July 2003. In addition, we reviewed FSIS guidance on when inspectors 

and districts should take enforcement action, and we talked with 16 of the 

17 DVMSs about their views on inspectors’ enforcement of the act and 

regulations; and we also talked with all district managers about how they 

determine when to take enforcement action against a plant. 

To assess the extent to which additional resources may be needed to 

ensure that humane handling and slaughter provisions are enforced, we 

contacted FSIS headquarters officials, district managers and deputy 
Appendix I: Scope and Methodology 

Page 33 GAO-04-247 Humane Methods of Slaughter 

district managers at the 15 FSIS district offices, and 16 of the 17 DVMSs. 

First, from FSIS headquarters, we obtained information officials put 

together on the estimated number of hours that inspectors devoted to 

implementation of the HMSA during fiscal year 2003. We also obtained 

documentation on the training available to inspectors regarding the HMSA 

and information on the agency’s upcoming plans to further address 

inspectors’ training needs and knowledge regarding the HMSA. Second, we 

conducted structured interviews with district managers and deputy district 

managers at all 15 FSIS districts to identify additional resource needs, 

such as additional inspectors, training, and guidance that would be 

necessary to ensure adequate implementation of the HMSA in their 

district. Third, we conducted structured interviews with 16 of the 17 

DVMSs to obtain their observations on how knowledgeable inspectors are 

regarding the HMSA and their training needs. We supplemented our 

analysis of the results of this work with interviews with Dr. Temple 

Grandin, a renowned animal-handling expert; industry association 

representatives from the American Meat Institute and the National Meat 

Association; and animal welfare group representatives from the Humane 

Society of the United States, Humane Farming Association, and Humane 

Farm Animal Care, which provided us with their views on improving 

HMSA enforcement. 

To assess the reliability of the FSIS data cited in the background section 

regarding plants covered by the HMSA, plant production, size of plants, 

plants covered by each district, and DVMS visits to plants, we (1) 

performed electronic testing for obvious errors in accuracy and 

completeness and (2) had discussions with agency officials knowledgeable 

about the data. We determined that the data were sufficiently reliable for 

the purposes of this report. 

We conducted our review from April 2003 through November 2003, in 

accordance with generally accepted government auditing standards. 
Appendix II: Comments from the Food Safety 

and Inspection Service 

Page 34 GAO-04-247 Humane Methods of Slaughter 

Appendix II: Comments from the Food Safety 

and Inspection Service 

Note: GAO comments 

supplementing those in 

the report text appear at 

the end of this appendix. 

See comment 2. 

See comment 1. (Page 

numbers in the draft 

report may differ from 

those in this report.) 
Appendix II: Comments from the Food Safety 

and Inspection Service 

Page 35 GAO-04-247 Humane Methods of Slaughter 

See comment 5. 

See comment 4. 

See comment 3. 
Appendix II: Comments from the Food Safety 

and Inspection Service 

Page 36 GAO-04-247 Humane Methods of Slaughter 

See comment 8. 

See comment 7. 

See comment 6. 
Appendix II: Comments from the Food Safety 

and Inspection Service 

Page 37 GAO-04-247 Humane Methods of Slaughter 

See comment 9. 
Appendix II: Comments from the Food Safety 

and Inspection Service 

Page 38 GAO-04-247 Humane Methods of Slaughter 

The following are GAO comments on the Food Safety and Inspection 

Service letter, dated January 14, 2004. 

1. We clarified our report to reflect this comment. 

2. We clarified our report to reflect this comment. 

3. We already include the fact that FSIS provided us with 553 

noncompliance records. Additionally, we acknowledge that the 44 

records that FSIS did not provide to us represent less than 10 percent 

of all the documented noncompliance records for the period. 

4. We acknowledge that the internal control problem we identified is 

being addressed. However, we cite the internal control problem 

because it affected the humane handling data for the period of our 

analysis—January 2001 to March 2003. 

5. The report clarifies that FSIS sampled approximately half of the 

available noncompliance records. We believe that we sufficiently 

indicate the differences in the approaches used by FSIS and us in 

analyzing those records. We acknowledge that the official who 

conducted the FSIS analysis is a trained veterinarian. However, our 

analysis relied directly on information provided by FSIS inspectors in 

noncompliance records. 

6. We clarified our report to reflect this comment. 

7. The final report clarifies that the 16 DVMSs we interviewed (out of 17 

DVMSs) told us that they originally participated in activities beyond 

the scope of humane handling and slaughter of animals. 

8. We have made a slight modification in the report language, but overall, 

we disagree with this comment. In our analysis, we did not attempt to 

reinterpret the narratives contained in FSIS noncompliance records 

that inspectors prepared after observing each violation. We 

categorized each record according to the type of violation to the HMSA 

and appropriate regulations. Regarding the first example in FSIS’s 

comments, if a noncompliance record indicated that it was issued 

because of ineffective stunning, that is the way we categorized the 

incident. Further, we did not attempt to impose a standard of whether 

or not documented noncompliance incidents resulted in animal injury 

for two reasons. First, FSIS did not provide us with any additional 

documentation, beyond the noncompliance records, indicating 

GAO Comments 
Appendix II: Comments from the Food Safety 

and Inspection Service 

Page 39 GAO-04-247 Humane Methods of Slaughter 

whether direct animal injury resulted from the incident. Second, 

whether or not an animal injury occurred is not a standard for writing 

noncompliance records, according to FSIS’s own directives. Finally, 

FSIS did not provide us with any additional examples or other 

information that, in their view, indicate that ineffective stunning 

violations reported in noncompliance records did not cause direct 

injury to animals, and therefore, did not result in actual “inhumane 

treatment.” The next three examples in FSIS’s comments do not 

pertain to ineffective stunning, but we used the same approach to 

categorizing these type of noncompliance records. 

9. We acknowledge that FSIS instituted a humane handling inspections 

system procedure code, effective October 2001, which should help 

FSIS better track noncompliance records that document HMSA 

violations. However, we note that this is a universal code for all HMSA 

violations and does not provide any additional information about the 

type or severity of the violation. 
Appendix III: GAO Contacts and Staff 

Acknowledgments 

Page 40 GAO-04-247 Humane Methods of Slaughter 

Lawrence J. Dyckman (202) 512-3841 

Maria Cristina Gobin (202) 512-8418 

In addition to the individuals named above, Pauline Seretakis, Heather A. 

Holsinger, Katheryn E. Summers, Charles T. Egan, John W. Delicath, and 

Jennifer R. Popovic made key contributions. Other contributors include 

Aldo A. Benejam, Michele C. Fejfar, Karen K. Keegan, Julian P. Klazkin, 

and Katherine M. Raheb. 

Appendix III: GAO Contacts and Staff 

Acknowledgments 

GAO Contacts 

Acknowledgments 

(360327) 
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